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3 Anthropology of Bioethics

图书名称:Writing at the Margin: Discourse between Anthropology and Medicine
图书作者:Arthur Kleinman    ISBN:
出版社:Berkeley: University of California Press    出版日期:1995年

The editors of the Encyclopedia of Bioethics invited me to write an entry on the anthropology of medicine. They asked that, in a short space, I show readers what the discipline is about and why it might be significant for ethical questions in medicine. I first sent them a contribution that centered on a cultural critique of bioethics. Clearly taken aback by the sharpness of the criticisms I leveled at mainline bioethics, they wrote me that my piece did not sufficiently describe the range of anthropological contributions, nor did they think I was up-to-date on new directions in medical ethics which already met the criticisms I had voiced. I returned to my study to read the more recent articles and books in bioethics that they recommended. That exercise did little to change my interpretation. However, I did take up their suggestion to expand the review of anthropological writings on ethical questions in health and medicine. The corpus is not huge, but it is larger than could be surveyed for a short article. Also, at the editors' request, I made the foolhardy effort to say something in a few paragraphs about medical anthropology more generally. Because it was so thin, that section is deleted from this chapter.

I also have added a response to several recent works by ethicists who have engaged multiculturalism. How could this not become a serious topic, if ethics is to have any pretense of being pertinent to North American as well as global realities. Indeed, I admire the effort of at least those few ethicists who have struggled to treat culture seriously, even if it is a very late trend. Nonetheless, I find the result highly inadequate. Culture, it would seem, is appropriated in ethical discourse largely in an outmoded manner aimed at creating a caricature—cultural relativism—that is meant to act as a foil for continuation of the business of moral philosophy as usual. Not a promising way to engage the multiple cultural realities of everyday life, one would have thought. There is one important exception. Prior to engaging the subject of this essay, I had not encountered feminist writings on moral philosophy. Several recent contributions to this genre I find impressive and consonant with the anthropological argument I advance below.

Admittedly this critique of bioethics as it is usually formulated is strong and fundamental. The reader will rightly wonder, therefore, why I end the essay by outlining an anthropological approach to clinical applications of bioethics. Because I am myself a physician as well as an anthropologist, I share the orientation of many patients and health professionals that the vexing question of human meanings, including contradictory ones, in the face of painful suffering and untimely death, is crucial to health care. If there is to be any approach in bioethics that engages culture, surely it needs to be one that deals with clinical realities, and to do so it must be anthropologically informed. This will not be a panacea; ethnography has its limits. But it is one way to begin engaging the multicultural reality of our times. That is my only defense for first indicting bioethics, and then turning around and offering a glimpse of what an anthropological turn in bioethics might look like.

Anthropological Contributions to Medical Ethics

Because of their concern with meanings and with the practical rationality of everyday decision making, anthropologists have written about the ethical sides of health and health care. For example, Peter Kunstadter (1980) and Morton Beiser (1977), anthropologically oriented psychiatrist, have discussed the ethical quandaries that development projects, including medical ones, introduce into poor rural Asian and African communities, because the services they provide are temporary and therefore raise expectations that eventually will be frustrated. Mary-Jo Good and colleagues (Good, Hunt et al. 1992) and Margaret Lock and Christina Honda (1990) have examined the moral exigencies of truth telling about cancer and determining death in biomedicine in Japan, respectively. The Japanese may be moving to accept brain death as a formal marker of death and thereby facilitate transplantation, which has been seriously constrained by Buddhist prohibitions, but it is, as Lock (1995) shows, a movement strongly contested by many Japanese who combine religious values about death with the most advanced technological orientation, rendering the distinction between "tradition" and "modernity" meaningless. Emiko Ohnuki-Tierney (1994) has shown that neither in Japan nor in North America can transplantation be modeled as some would suggest as a gift-of-life, since gift exchange relations require reciprocity in socio-moral transactions that is simply lacking in transplantation. Rather the technology of transplantation leads to a series of cultural transgressions of categories of human/nonhuman, rationality/emotion-spirit, self/other, and life/death that remake what is regarded as "natural" into a new cultural form, a way of being-in-the-world that is unacceptable to many in Japan and which, Ohnuki-Tierney argues, would, if more fully understood in the West as a fundamental alteration of social experience, be unacceptable to many there as well.

Paul Unschuld (1979) analyzed the corpus of Confucian writings and traditional Chinese medicine texts that deal with ethical issues and concluded that professional and cultural values of the literati class colluded to control the medical marketplace. I found that healers in Taiwan in the 1960s and 1970s, regardless of whether they were practitioners of traditional Chinese medicine, shamans, or physicians, were viewed by patients as morally ambiguous: powerful to heal; yet potentially an immoral source of economic gain and even of evil power (dangerous technological procedures or sorcery) (Kleinman 1980: 240, 284, 303–304). This finding of the moral ambivalence central to therapeutic practice would appear to be rather widespread cross-culturally.

Horacio Fabrega (1990), writing explicitly about an ethnomedical approach to medical ethics, sees biomedicine's ethical preoccupations growing out of Greek medicine and from the popular morality of ancient Greece. Following many anthropologists, he asserts that in small-scale, preliterate societies, healing and religion are inseparable; thus, medical mores are tied to ritual and theology in those societies. In larger-scale societies—both peasant and industrialized—the specialized division of labor leads to practitioners who are popularly viewed both as healers and as financially benefiting from the healer's trade. Fabrega argues that all the great non-Western traditions of healers use ethical injunctions to control access to practice and to proscribe certain alternative healers as quacks. He asserts that "bioethics" is a unique version of medical ethics made possible by the development of biomedicine with its knowledge of biology and powerful biological applications. Michel Foucault (1973:199) presses this argument beyond morality. "Bio-power," in the Foucaldian vision, links morality and science and clinical practice through cultural shaping of experience with the deep political processes that are at work in society (Foucault 1980). This line of analysis has been influential among many medical anthropologists.

Writing for a collection of social science treatments of bioethics, Richard Lieban (1990) focuses on anthropological interest in the ethical aspects of controversial local practices such as female circumcision, differential assistance to male children, and the lack of regulation of folk healers as examples of what anthropologists can offer to bioethical issues in international health (see also Grunebaum 1982; Kleinman 1982; Korbin 1981; Scheper-Hughes 1987). Allan Young (1990), in the same volume, demonstrates the value of ethnographic accounts of the hidden moral dimensions of psychiatric practice in a Veterans Administration unit for treating combat-related posttraumatic stress disorder (PTSD) among ex-soldiers who served in the Vietnam War. He argues that what is a psychological crisis or psychiatric disorder in the individual patient for mental health professionals is, for the anthropologist, a crisis or disorder in the politics and ethics of the social body. Vietnam veterans with PTSD are not so much victims of a mental disorder as they are victims of (and victimizers through) the political decisions of their nation's leaders. (See also Young 1993, as well as the review of Young's forthcoming ethnographic monograph in chapter 9 below.)

What characterizes anthropological approaches to ethical issues, in medicine as well as other fields, is an emphasis on questions that emerge out of the grounded experiences of sick persons, families, and healers in concrete contexts. Anthropologists have critiqued universal ethical propositions just as their professional perspective has led them to critique universalist models for economic development. In place of universalist and essentialist propositions—philosophical or political economic—anthropologists, always more the intellectual fox than the hedgehog,[1] have focused upon the interactions of everyday life, the societal hierarchies and inequalities they represent, and the moral issues in which they are clothed. Thereby, anthropologists examine ethics at the intersection of the social logics of symbolic systems, social structures, and historical events (Augé 1984).

In the anthropological imagination, a distinction can be made between the "ethical" and the "moral" (Kleinman and Kleinman in press-a). Whereas ethical discourse is a codified body of abstract knowledge held by experts about "the good" and ways to realize it, moral accounts are the commitments of social participants in a local world about what is at stake in everyday experience. Both are cultural processes, but of a somewhat different kind. As Richard Shweder (1991: 186–240) shows in his research on moral experience in an Indian city, the canonical code becomes part of the moral socialization of children in families. But it is appropriated into settings where many other things are at stake in the local politics of interpersonal relations (Kleinman and Kleinman 1991). While the ethical code informs those relationships, the struggles over differing interests mean that everyday life is inherently a moral process. Moreover, the contexts and process of moral life involve more than individuals. They also are based in collective orientations, social resources, and intersubjective action. The moral is actualized not only in subjective space but in social transactions over what locally matters, often vitally so, such as marriages, family, work, child rearing, education, religious practice, health, death. Conflicts among different priorities create moral dilemmas as social problems that require action.

Thus, Kenneth Read (1955) writing about the Gahuku-Gama of Papua New Guinea, argued that moral issues for this preliterate group were experienced primarily as problems and prospects in social relations. The moral was not viewed as a distinct sphere separate from the rest of life. For the Gahuku-Gama, "moral judgement is largely of a contextual character" (p. 281). They will not judge moral situations in the abstract in which they have not been personally involved. Like the Chinese, the Gahuku-Gama's image of the person is of a relational self, a self in which social interactions, rather than the rationality and free will of the person, are the basis for moral judgment. Not violence in the abstract, but particular violent acts in particular contexts are evaluated morally. For Chinese, morality is also about persons interacting in concrete situations; it is about the subordination of the self to that social relational context of experience, and indeed about the person's use of an interpersonal idiom of what matters—for example, filiality, social favor, "face"—to find and express his or her moral choices (Fei 1992). For the Chinese, social order is more important than self-realization; self-restraint takes precedence over self-expression. But these are not to be understood as different beliefs or values; rather they represent distinctive ways of being-in-the-world, different modes of social experience. As Brad Shore (1990), working in Samoan society, notes, moral decisions are driven not by abstract values but by practical dilemmas, such as whether to respond to a leader's anger toward a kinsman with meek acceptance or violent resistance. Moral decisions, then, represent conflicts between distinctive forms of social action. This is quite a different appreciation of what morality is about than that held by mainstream moral philosophers or theologians in the West.

The remainder of this chapter will adumbrate what anthropological studies tell us about health, illness, and care that is relevant to the practice of bioethics. I start with a cross-cultural critique of leading bioethical orientations and commitments. Thereafter, the more substantial anthropological contributions will be reviewed, followed by a brief discussion of the possibilities and problems with a culturalist orientation. From the anthropological perspective, bioethics shares with biomedicine several inveterate cultural orientations that constrain the standard approach to moral issues in patient care. The anthropological approach, therefore, becomes particularly useful because of the comparative understanding it brings to the analysis of unexamined biases.

The Culture of Bioethics

The ethnocentrism, psychocentrism, and medicocentrism central to biomedicine are also prominent in the standard bioethical approach (see Lock and Gordon 1988; Weisz 1990). Most philosophically trained bioethicists draw on what Charles Taylor (1990) describes as the orthodox sources of the self in the Western philosophical tradition. The canonical works in that tradition, from those of the Greeks down to the present, assume an individuated self, set off from the collective—single, unchanging, self-defining. Thereby, inter alia, the autonomy of the person is claimed to be a paramount value along with the ideas of justice and beneficence. From a cross-cultural perspective this intellectual commitment, which is reinforced by the deep subjectivism of the Western tradition, is problematic.[2]

Few members of non-Western societies—such as China, India, Japan, or most Southeast Asian or African societies—hold the view that the isolated individual is the locus of responsibility for therapeutic choice, or that therapy should work to maximize the individuation of the sick person, or that personal authenticity is fundamental to health and well-being.[3] Rather, there is usually a paramount sociocentric consensus in which social obligation, family responsibility, and communal loyalty outweigh personal autonomy in the hierarchy of ethical principles. The self, even where it is held to be uniquely individual, is viewed as sociocentrically enmeshed in inextricable social networks, intimate ties that make interpersonal processes the source of vital decisions. More than 80 percent of the planet's population live in cultures outside of North America and Western Europe or are members of minority ethnic groups outside of the Euro-American majority. Among these cultures and ethnic groups, autonomy is often a much less significant value than other, more sociocentric ones. That bioethics is able to avoid serious engagement with these alternative ethical traditions must represent one of the last tenacious holds of ethnocentric mentality. Indeed, there is evidence that bioethicists are commencing such decentering cultural engagements (Jennings 1990; Loewy 1991).

The idea of the primacy of the individual is still, however, the unexamined cultural presumption of Westernization. Spread throughout the globe first by the military successes of colonialism and later by the even deeper forces of postindustrial capitalism, whose commercialism is built so intimately around individual desires, the imagery of individualism has become the international order's central value orientation of "rights." Thus, the very goals by which societies, Western and non-Western, are evaluated turn on the commitments of Westernization. International trade, international peace and security negotiations, international development policies, and international health programs prioritize this value commitment of personal entitlements or consumer preference as fundamental to the enterprise of globalization . For this reason, it is not enough to contrast Western and non-Western ethical claims, since the very idea of ethics privileges the Western view of the individual. Globalization brings the deep subjectivism of that ethical design with it, so that that social transformation itself becomes a process of hypertrophic individualization. Simply comparing individualism with sociocentricism, therefore, can never be sufficient. It is essential to make the critique of individualism central to a cross-cultural approach to ethics.

I do not dispute that the international movement on behalf of individual rights frequently has had a laudable effect, especially in highly repressive polities, but I am challenging the cultural assumptions it carries, which too often work to reinforce some of the more negative aspects of Westernization, such as its Orientalism—the construction of cultural difference as an irreducibly alien otherness—and its dissolvent effects on other social modes of experience.

Similarly, from an ethnographic perspective, the use of abstract concepts of justice and beneficence as universal ethical principles in decision making is suspect. This in part restates the cultural critique of individualism. Yet there is also a failure to take into account the local worlds in which patients and practitioners live, worlds that involve unjust distributions of power, entitlements, and resources. It is utopian, and therefore misleading, to apply the remote principles of justice and beneficence to ordinary clinical problems, unless we first take into account the brutal reality of the unjust worlds in which illness is systematically distributed along socioeconomic lines and in which access to and quality of care are cruelly constrained by the political economy. The most desperate and predatory of these contexts would seem, by their very characteristics, to exist somewhere beyond the reach of justice. Beneficent social contracts may make good philosophical theory, but they deny empirical experience in local social worlds. The moral philosopher's "beneficent community" (Loewy 1991), which in ideal terms is supposed to be concerned with minimizing the suffering of its members, is a charming romance; no one lives in such a utopian state. Rather, real communities are sources of suffering at least as much as sources of assistance. They do not contain explicit social contracts, but they are filled with explicitly different interests, status differences, class divisions, ethnic conflicts, and factionalism. Little is gained by installing utopian virtues; in fact, much is lost, since illusion and exaggeration distort the practical realities among which most people on earth live.

Again, this is an instance of the danger of ungrounded analysis of the sources and consequences of ethical choices. On several occasions, I have heard philosophers, who otherwise have made trenchant criticisms of epistemological and ontological positions, intervene in a discussion of medical ethics by adverting to the example, "Suppose a Martian were to land on earth and were faced with such a problem." The illustration is probably meant to explode conventional common sense. Yet it is a telling method to introduce into the discussion of a particular case, because it so cavalierly steps outside the powerful constraints of real worlds. Happily or unhappily, there are no Martians; there are unfortunately, many, many humans on our planet who are faced with desperate choices in situations in which the concrete details of historical circumstances, social structural constraints like limited education and income, interpersonal pressure, and a calamity in the household or workplace are at the core of what a dire ethical dilemma is all about. Thus, there is a deeply troubling question in the philosophical formulation of an ethical problem as rational choice among abstract principles, because that problem is always the burden of a man or woman's particular world of pain and possibility. That social space contains the flows, routines, and everyday practices of moral experience. Ethnography, biography, social history, literature—all contain methods of entering those local social spaces. They see moral issues from the inside of experience, where those issues appear as they are so often lived, as fragments, incoherences, things beyond one's control. Intellectualist perspectives that universalize ethical choice are flawed, at least for application to serious conflicts in the human experiences of illness and care, because they are, in a fundamental way, groundless. "Psychocentrism" also installs mind-body dualism, a near fatal flaw for an approach to the experience of illness and treatment. But discussion of that intellectual cul-de-sac would overwhelm the other issues I need to review, and so I set it aside for another occasion.

The third "centrism"—medicocentrism—emerges from comparative studies as yet another bias of standard bioethical discourse. Like biomedicine, bioethics begins with professional definitions of pathology. The disease viewed as pathological physiology along with the professionally authorized array of treatment interventions define the clinical situation (see Canguilhem 1989). The experience of illness is made over, through the application of ethical abstractions such as those described above, into a professionally centered construct that is as divorced from the patient's suffering as is the biomedical construction of disease pathology. The patient's experience is appropriated by the rational technical categories of professionals.

The bioethicist, of course, is supposed to take into account the patient's perspective. But by and large the contextually rich, experience-near illness narrative is not privileged. It is reinterpreted (also thinned out) from the professional biomedical standpoint in order to focus exclusively on the value conflicts that it is held to instantiate. The categories of patients and indigenous healers are provided with only limited legitimacy; they are after all called "folk," a derogatory label. If they can be restated in the abstract terms of the standard bioethical orthodoxy, they are provided a place in the analysis. But if they cannot, then "folk" categories lose their authoritative imprint to define what is at stake for patients and families. (One extraordinary exception worth applauding is Hoffmaster's [1992] call from within moral philosophy for a more situational, ethnographic turn in medical ethics that is open to the empirical realities that hedge moral questions. See also Davis's [1991] call for thick description in medical ethics.)

Take ideas, for example, of suffering —a powerful category in popular cultures worldwide that points to the experiential basis of values. One is surprised to find so many professional ethical volumes in which this word does not even appear as an entry in the index. Indeed, Eric Cassell stands out in both biomedicine and bioethics for writing explicitly about suffering as grounds for research, practice, and theory (Cassell 1982; 1991b). Ethical systems that leave the problem of suffering (and related concepts of tragedy, endurance, and courage) to particular theological or poetical traditions do not adequately engage the human core of illness and care (see Bowker 1970; D. Morris 1991: 261–268). Here perhaps the standard version of bioethics shares yet another biomedical bias, the rejection of teleology (see Emanuel 1991). Biomedicine banishes purpose and ultimate meaning to religion, yet most patients and practitioners struggle to make sense of illness with respect to great cultural codes that offer coherent interpretations of experience (cf. Frye 1982). So important are these codes for patients that efficacy of intervention cannot easily be disentangled from popular conceptions of coherence and significance. Serious suffering is almost always about ultimate meanings, not always theodicy, a decidedly Western issue, but nearly always about what ultimately matters in a particular local world.

A commitment to medicocentrism also leads bioethicists to construct cases that are centered in the professionally approved institutional structures of biomedicine, such as hospitals or clinical research centers, even though most illness episodes, as social studies readily reveal, are experienced, interpreted, and responded to in the context of the family. The family—the mundane, cultural setting of illness and care, where local social processes are so greatly influential—together with the workplace frequently disappear in bioethical discourse, to be replaced by the biomedical staging of more extreme, even exotic value conflicts. Of course, the immense panoply of popular healing settings is even less visible or audible in the bioethical construction of clinical reality.

That professional bioethicists have in the past framed ethical questions in high-price, high-tech, high-drama biomedical settings—neonatal intensive care units, surgical suites, coronary care wards, cancer clinics, emergency rooms—is justifiably arresting. These are after all the same supremely charged arenas that are central to biomedicine's self-image as the cutting edge of the high-technology battlefield where war is waged against death itself. These arenas of soaring technological power are also, of course, the high-status images of the society at large. By placing the most fundamental ethical queries in these settings—the original ethical scene if you will—bioethicists quite obviously, ipso facto, have laid claim to that powerful imagery, to those most highly paid health professionals, and to their preeminent status. Not an unreasonable means of fast forwarding the agenda of a relatively new discipline, and yet, in the bargain, something crucial has been lost. Because the biomedical location of ethical issues draws attention away from the mundane worlds of suffering where most illnesses are enacted and most treatments undergone, voice is denied to the vast majority of health problems and outcomes. The extreme is emphasized over the routine. Medical morality is configured as crisis. The primary care clinic, the nursing home, the occupational health unit, the public health nurse's office, places alive with ordinary doctoring and nursing and patienthood, simply are not given the same moral weight as the high-technology settings. Even less are lay settings privileged as the locus of moral choices, yet from an epidemiological standpoint, that is their locus. A patient- and family-centered bioethics oriented to the routinization of suffering is not invisible, but clearly, as in biomedicine, it has been made to count for less.

From the vantage point of social theory the argument might be advanced that bioethics has received authorization to use abstract philosophical terminology that shares a value orientation with biomedicine in order to construct the moral domain in health care so as to assure that professional medical dominance will not be seriously threatened by lay perspectives and everyday life experiences that might generate a deeper critique of that medical-moral domain and the economic interests with which it is inextricably tied. Professional dominance is maintained, in this view, via the development of a new profession—bioethics: a handmaiden to the powerful medical bureaucracies and associations of professionals, which itself gains jobs, prestige, and a degree of influence from this social assignment. An uncharitable social science observer might even point to the exoticism so characteristic of the extreme examples bioethicists favor as evidence of mystification, this profession's unwillingness to challenge the everyday organization and practice of care.

I would suggest caution in accepting this analysis. Whether as presently constituted it does so or not, bioethics has opened up a legitimated space to examine moral issues of illness and care—a space, moreover, that is located in the very heart of biomedical institutions where in principle, if still not in daily practice, the social world of patient, family, and the community can be made a legitimate part of clinical conversations. Hospital ethics committees, institutional review boards for medical research, the clinical ethicist on the wards, and the development of academic programs focused on regulatory and more broadly societal ethical issues may be, at least at present, unduly influenced by powerful institutional forces, such as the micropolitics of the "interests" of hospital directors, medical staff committees, and the barons of biomedical research, yet the very presence of these bioethical activities legitimates alternative perspectives. They hold the very real potential for importing into the center of biomedical institutions a sharp cultural critique of the biomedical order and its practices.

Furthermore, I do not subscribe to the vision of biomedicine as a monolithic force. The medical profession, the hierarchy in a hospital, the ethical review boards, and the scholars at work developing the discourse in bioethics are greatly heterogeneous. Different interests and different idioms for communicating about moral problems thrive. The work of bioethics goes on in local fields of power—societal, institutional—in which contestation is intrinsic and social processes take unprecedented turns. Indeed, the profession of biomedicine may be a much smaller player than other interest groups, such as insurance companies, health maintenance organizations, corporate health plans, and political coalitions, whose power has grown during the national struggle over health care financing in the United States. Certainly, in North America whatever biomedical (and bioethical) hegemony exists is hedged in by many forces—the state, the corporations, local government, patient interest groups, and professional critics from social scientists to newspaper columnists. In this contested field of power it is by no means certain that particular activities in bioethics or groups of bioethicists will support the interests of the profession or of its major institutions: indeed some clearly do not (e.g., Callahan 1987, 1990). Bioethics, like the varieties of clinical practice, could (and sometimes already does) offer internal resistance to the imposition of the interests of the technical biomedical discourse over those of patients, families, and the community. And that, I will assert, is a very good thing.

What an Anthropological Turn in the Practice of Bioethics Might Offer

The portrait of bioethics that I have drawn is all too black and white. I have done so for heuristic purposes in order to draw out the deep difficulties and underline their cultural sources. In the practical flow of events, working bioethicists, like hard-pressed clinicians, struggle to overcome these constraints that limit their engagement with the obdurate particularity and inexpedient uncertainty of their human subjects. And for that very reason the bioethicist will find an ethnographic orientation liberating, even if ultimately she or he is frustrated by its limits too.[4]

In contrast with the bioethicist, the ethnographer begins with the lived flow of interpersonal experience in an intensely particular local world. Not the Western tradition, or North America, nor even New York State, which are too unspecified to provide a positioned view from somewhere (Nagel 1986), but rather the Puerto Rican community in the South Bronx, upper-middle-class Scarsdale, a working-class section of Queens, or a network of Russian immigrants in Brooklyn becomes the setting for grounding moral analysis in the concrete historicity, micropolitical economy, and ethnicity of a local world. Even within such a localized flow of experience, perspectives and preferences are further defined by gender, age, and other social categories of persons: for example, the cultural situation of poor women in rural Haiti who are responding to AIDS (Farmer and Kleinman 1989). These indexes of social experience situate groups and their individual members along axes of power such that the force of macrosocial pressures—economic depression, forced uprooting, ethnic conflict, state violence, the organizational control of substance abuse, the social structural sources of chronic illness and disability—is systematically attenuated for some yet amplified for others. Some become successful or at least are protected; others are victims.

Each local world is characterized by what matters for its members. That structure of relevance gives to the meanings of illness and to treatment expectations the sense of something much closer to natural law than a belief or a convention. Families hold the world to be a certain way as an article of fundamental faith in local reality, not as a debatable position in a self-conscious philosophical reflection. In the infrapolitics of family, workplace, and community, which can be described empirically, the processes of strategic negotiation and interpersonal engagement over what is at stake can be properly regarded as those through which a local moral order (i.e., lived reality) is constituted and expressed. Culture, then, is built up out of the everyday routines and rhythms of social life. It is the medium of collective experience, for example, in which chronic pain affects an entire work unit, Alzheimer's disease is shared as an illness reality by a family, and pediatric cancer care is negotiated among parents, child, and professional care providers.

Hospitals, clinics, and disability programs also are grounded in the particularity of localities, as is the bioethicist. The ethnographic task for the practicing bioethicist, then, becomes the discovery of the meanings and relationships in distinctive local worlds, and the interpretation of their actual impact. This process of discovery creates a coherent narrative out of interactions that are ambiguous and changing. This is a type of cultural construction of the moral conflicts and negotiations that take place over plans and practices that make up the flow of everyday living. Unlike the illusion of abstract rational choice, the ethnographer discovers the murky indeterminacy of real lives and the messy uncertainty of real conditions—conditions in which moral dilemmas and contradictions are inherent in the field of transactions, in the flow of social life itself. Though itself a coherent account, the ethnographic narrative must express these incoherencies, this frustratingly nonstop process of social action.

As part of this ethnographic work, bioethicists need to elicit the perspectives of the participants and place them in the contexts of family, workplace, and medical system. To interpret those grounded perspectives, however, they will need to construe the local context in the light of larger societal influences. Thus, by bringing the life world of the patient into biomedical deliberations, bioethicists also bring with that biographical narrative a much larger societal analysis.

The bioethicist's involvement should be to facilitate communication and to help negotiate conflicting orientations. In this work, it is necessary to protect the participants from the dehumanizing imposition of hegemonic principles like autonomy and justice. The focus on the positioned, intersubjective perspectives of participants in a local context—part of what Sen (1994, and see chapter 4 below) means by positioned objectivity—is a radically different vision of how to proceed with the ethical analysis of a case than that which originates in a philosophical quest for an illusory transpositional objectivity, a definitive synthesis, an authoritative voice valid for an entire context or for multiple contexts. In the anthropological vision, such a transcendent objectivity is the problem, not the solution.

More specifically, anthropological analysis draws attention to the institutional context of ethical decision making (see Bosk 1979; Fox 1990; Mizrahi 1986; Zussman 1992). Social institutions—a particular type of hospital, a clinic for alternative care, or a religious facility—refigure ethical issues in terms of efficiency and other technical criteria as well as larger social value orientations that make up everyday social routines. Hence, the special characteristics of a Veterans Administration Hospital (VAH), a university-based teaching hospital, a military emergency unit, a for-profit hospital chain, or a highly cost-conscious HMO constrain the day-to-day social processes that create the local moral order. What is at stake for a resident in training in a teaching hospital—generating new knowledge, securing a place in the academic hierarchy, and so on—is noticeably different from what is at stake for a practicing physician at a small community hospital. The difference signals a distinctive institutional context for deciding what level of treatment is "routine," which kinds of issues will be highlighted as "ethical" problems, when and how substantially families will be involved, and so on. Quite obviously, institutional contexts will also be distinctive cross-culturally. In Japan, even in a university teaching hospital, the practice has been not to disclose the diagnosis to patients who are suffering from cancer but to allow key family members to decide if and when "truth" will be told to the patient. In China, as in other non-Western societies, the family members will stay in the hospital with the patient to do the nursing, prepare meals, and make all the major decisions even for the family head when he is seriously ill.

In Zaire and Senegal, members of the kinship-based therapy management group, including perhaps the doctor and the nurse, will decide if the patient is to be part of a research protocol (Beiser 1977; Janzen 1978). In a Seventh-Day Adventist mission hospital run by American staff in Borneo, the structure for identifying and resolving a moral dilemma will draw on a religious ideology that suffuses the institutional context quite differently than that of nearby medical facilities run by transplanted Javanese Muslims or local Dayak animists. I have compared the responses of North American and Chinese psychiatrists to depressed patients in the United States and in China with respect to their decidedly different institutional contexts for determining what kinds of therapeutic behaviors represent good care and what kinds of moral messages will be given and received in the patient-doctor interaction (Kleinman 1988b:77–108). North American psychiatrists, practicing psychotherapy in outpatient settings where they are paid by patients for each individualized hour-long session, explore pathologies of the self (low self-esteem, narcissism, masochism, "excessive" guilt) with the aim of "helping patients to individuate." Psychotherapists refrain from giving specific advice about concrete decisions lest they usurp the patient's existential responsibilities to the self, including the responsibility to succeed or fail with authenticity, on one's own . In the hospital-based practice of psychiatry with its powerful emphasis on the efficiency of getting patients discharged before insurance payments run out and with the outcome objective of getting the patient back to full function (in household and workplace), care is less "permissive" and much more "directed."

The different metaphors are different forms of moral practice. In China, salaried, hospital-based psychiatrists exhort patients with strong messages about what to do or not do, inasmuch as patients are seen as suffering from "autistic" (read, overly individual) desires for which they require disciplined reeducation and resocialization in collective responsibility. Patients perform in group events that range from listening to lectures to singing inspirational, politically authorized songs. Protecting the social order is paramount; patient rights, at least until very recently, have carried little cachet. The development of psychological counseling centers in Chinese urban areas, even if for treatment of only one or two sessions, however, has promoted a kind of treatment that combines aspects of each of the above forms of practice. Thus, institutional values modify and inflect cultural orientations.

Renee Fox and Judith Swazey (1984) have shown how physicians in a Chinese hospital draw on both Confucian views and communist ideology to authorize local patterns of ethical decision making that challenge North American orientations, but that also are changing under the pressure of societal and institutional transformation. Cultural historians disclose how bioethics in North America itself has emerged out of the social problems and responses of a particular era (Rothman 1990). Thus, in the 1960s and early 1970s, informed consent became central to bioethics at a time in which this theme resonated with ethical problems in the political system; just as ethical concern for the limits of treatment and rationing of care, so central to the bioethics of our time, is linked to the political economic crisis in health care (Marshall 1992). Following the Tiananmen Massacre, criticism of China's gulag and its human rights abuses has pressed Chinese psychiatrists to at least make an appearance of addressing patient rights and to dissociate themselves from the highly publicized abuse of dissidents associated in the recent past with East European psychiatrists.

Anthropology (and other interpretive social sciences), then, brings to bioethics a critical approach to the cultural roots of ethical systems and to the cultural process of moral action. The works of moral philosophers who have themselves begun to engage cultural difference indicate why an anthropologically informed understanding of culture that is based in ethnographic study of the lived context of moral experience is essential to such an undertaking. For even such an encompassing yet disciplined moral philosopher as Charles Taylor (1992b) loses his way in the thicket of multiculturalism. Taylor applies a masterly analysis to the contemporary politics of recognition of ethnic difference, in which he seems to move beyond the usual catechisms of individual rights to establish the importance of the right for communities to animate distinctive moral worlds, only to conclude with the rather disappointing cliché that what we need is to show "respect" for other cultures. Coming from one of the major moral thinkers of our era, this surely is not promising.

Another influential moral and political philosopher, Amy Gutmann addresses "the challenge of multiculturalism" by setting up cultural relativism as a "strawman" (Gutmann 1993). First finding fault with a radical version of ethical relativism, in part because, she claims, it fails to register intracultural diversity and change and in part because it fails to recognize that moral reasons can be rationalizations of differences in social power, Gutmann goes on to attack the idea that failure to recognize cultural difference injures ethnic (and self-) identity. Since cultural relativism, she insists, would render justice relative to shared meanings of social goods and since its association of shared meanings and identity is false, cultural relativism's approach to justice is invalid.

In its place she calls for a deliberative universalism that would partly rely on a core set of universal principles of justice which apply to all "modern cultures" and that would also put faith in accountable deliberation to address fundamental conflicts over social justice.

Now, in fact, I shall argue below for an approach to bioethics in clinical settings that is very much like Gutmann's deliberative universalism, though my emphasis is on a method that might be called deliberative relativism. But where Gutmann abandons "culture," under the authorization of a faulty syllogism, I regard it as central to the very process of deliberation, which I will call "cultural engagement." The problem with Gutmann's analysis is her failure to recognize the current understanding of culture within social anthropology. Social anthropologists today define culture not as shared canonical meanings that are distributed equally throughout a community, but rather as lived meanings that are contested because of gender, age cohort, and political difference; meanings that are actualized differently in everyday social transactions so that they exert a partial, uncertain effect are really practices, ways of being-in-the-world. By this definition culture is emergent in particular social interactions. It is neither homogeneous, nor determinative, nor unchanging. And since the misadventures of the culture and personality school in the 1950s, few anthropologists would make a direct one-to-one association of culture with personal identity. A cultureless deliberative universalism may sponsor a useful method for dealing with a particular difference in the theory of ethics. Because it makes no room for culture, however, it begs the question of ethnic and cross-cultural difference, and also, and perhaps most troubling, misrecognizes that the process of ethical deliberation itself is contextualized, emergent, and cultural.

In a more complex argument about culture and ethics, Jorge Garcia (ms.), a moral philosopher and bioethicist, examines several kinds of cultural relativity. He explicitly differentiates a radical relativity ("comprehensive relativity") from "limited relativity." He follows Gutmann in criticizing those who propose "seriously relativist positions" for avoiding the problem of intracultural diversity. He also castigates serious relativists for being capable of bearing only a shallow liberalism, for example, a defense of tolerance—a position he recognizes may be seen as Eurocentric, yet one which he regards as crucial to ethics. Garcia then proceeds with an argument based upon the same inadequate formulation of culture as that held by Gutmann, albeit at least including a place for a stripped-down notion of culture.

Garcia, as he himself recognizes, falls into the problem of ethnocentrism, in this case willfully. But the larger problem is that Garcia misrecognizes moral deliberations. He sees them as deliberations that transcend or avoid culture. He does so by relying, as does Gutmann, on an idea of culture as beliefs, values, and judgments: conventions that can be taken up or put down at will. An idea that leads to simple ethnic stereotypes that are rejected by ethnographers does not offer a promising modus operandi . That culture is also a process of action, a mode of collective experience, an emergent in local relationships and situations is not a view Garcia (or Gutmann for that matter) would endorse. If they did, much of their argument against cultural relativism would dissolve.

In a very recent piece, Nancy Jecker, a bioethicist, and clinical colleagues (1995) propose a set of guidelines for engaging ethical issues in cross-cultural patient care that is quite close to the procedure outlined in this chapter. The process of negotiation they set out is one that can only improve ethical approaches to patient care. Particularly impressive is their openness to alternative perspectives and their seriousness in requiring that genuine patient-provider negotiations over fundamental moral commitments be at the center of bioethical deliberation. Perhaps because this useful clinical methodology is buttressed by real cases of Navajo patients, we are even more aware of the limitations of the conceptual frame that the authors share with Gutmann and Garcia. Values become a surrogate for culture; the description of the local cultural setting is limited to that of the patient's personal history; neither the culture of the clinic, the cultural mode of ethical practice, or financial and bureaucratic interests are brought into the analysis; and the central role assigned to "ethical integrity" is presented as if this mode of behavior were not founded on a very Western set of deeply subjectivist commitments regarding the self, the other, and what is at stake in their relationship. One might well assume that when ethicists finally get around to dealing more adequately with an anthropologically oriented appreciation of culture as moral context, process, and performance that the strategies proposed for clinical practice will be more far-reaching and original. A promising early example is the research program Barbara Koenig and colleagues at Stanford and University of California San Francisco have organized to examine how discussions about terminating care actually proceed among terminal cancer patients, their families, and caregivers across Asian American, African American, and Mexican American groups.

What the philosopher Hans Sluga, in his discussion of Heidegger's mixing of philosophy and politics under the Nazis, writes about the relationship of philosophy and politics (1993) generally will be too strong to transfer verbatim to the relationship of philosophy to ethics. Nonetheless, if in the following excerpt the word "ethics" is substituted for "politics," we are left with a sense of shock that may be worth carrying over into bioethics, not because it describes what exists, but because it cautions against a certain danger while appealing to an impressive strength of what philosophy can do:

Philosophers, in my view, are not qualified to lay down authoritative standards of political action. Whenever they have tried their hand at this, they have either described useless utopias or given dangerous instructions. It might be more attractive to think of them as playing a critical role. But political critique is productive only if it is tempered by common sense and practical experience. Philosophical critics of politics, on the other hand, proceed all too often from supposedly absolute truths, and what they say then proves generally unhelpful and sometimes even destructive. Insofar as philosophy has any task to perform in politics, it is to map out new possibilities. By confronting actual political conditions with alternatives, it can help to undermine the belief that these conditions are inevitable. If the German philosophers of the 1930s had engaged in such reflection, they would not have surrendered so readily to the false certainties of Nazism. (pp. ix–x)[5]

That it is possible for moral theory, and bioethics in particular, to open a different and more substantial pathway toward culturally salient issues is confirmed by the approach to ethics in a pluralistic society that, as I have already noted, William Connolly draws out of the works of Nietzsche and Foucault for an ethics of agonistic generosity. That continental approach to the diversity of moral meanings encourages empathy for contradiction, contestation, and paradox in a world without an intrinsic moral rule. (James Fernandez [1990] shows how much the same stance emerges from the relativist program in anthropology.) Another promising direction is to be found in the writing of Marion Young (1990) on justice and the politics of difference. Young holds that moral judgment should commence with an understanding of domination and oppression in real social spaces. Her feminist perspective emphasizes that "rights" are more validly conceptualized as relationships and institutionally defined social roles than as things. Because relationships and institutionalized roles take their origin from differences in power, morality must be about those differences in power as found, for example, in cultural imperialism or paternalism.

The focus of ethics should be to empower groups who are the victims of relationships of dominance. For Young, "social justice involving equality among groups who recognize and affirm one another in their specificity can best be realized in our society through large regional governments with mechanisms for representing immediate neighborhoods and towns" (p. 248). Because autonomy at the individual and group level means exclusion of others, she defines justice without privileging ethnic autonomy. Rather her vision is one in which interaction and exchange are the sources of a morality in which difference can flourish among a heterogeneous public. Again this feminist critique possesses much the same thrust as anthropology's relativist interpretations. In both, pluralism and difference are not to be feared; they are affirmed as the source of moral experience, not a threat to moral practice.

Besides cultural critique and comparison, is there a practical contribution anthropology can make to bioethics? The cultural formulation of diagnostic and therapeutic issues clearly should be as significant to the consulting bioethicist as the medical anthropologist can frequently make it for the consulting physician, especially when the patient and family come from cultural and ethnic backgrounds that differ from those of their professional caregivers, or when the setting is outside North America (Kleinman 1982). That formulation involves systematic steps in placing the illness and treatment experience in the culturally grounded context of family, work, and medical/social welfare systems, through the application of a highly focused ethnography—a description and interpretation of how those settings affect, and are affected by, the illness. Cultural formulation identifies lay and professional explanatory models, compares them for evidence of cultural bias or conflict, and sets out a process of negotiation to assure that their inhabitants benefit from studies of cultural sensitivity (see Helman 1992; Kleinman 1988a:227–251; Rogler 1990). These are technical procedures, albeit experience-affirming ones, that can become part of the repertoire of the bioethicist. Ethnographic knowledge of the core ethical orientations and social patterns of different communities will be especially significant in planning and implementing medical research in low-income ethnic and non-Western settings to assure that their members benefit from studies that place them at risk as much as do the wealthy Euro-American groups that sponsor such projects (Christakis 1988).

As this last example suggests, the ethics of the sickroom and the clinical encounter are only one side of medical ethics. Especially important for anthropology are the vexed questions of societal ethics. These questions turn on the control and allocation of resources that underwrite health status and quality of care. They are inseparable from issues of social value, political economy, and history. Societal ethics in North America, for example, needs to be discussed in the political context of the social transformation of North American society and its medical institutions. The ethnographer can examine how these macrosocial changes affect sickness episodes and treatment practices in particular local settings that differ in their rates of unemployment and health risks. That contextual knowledge—for example, of particularly salient local instances of institutional racism and their aftermath in hostility and resistance—is what is missing in medical ethics. The ethnographic method would reshape bioethics's almost single-minded interest in government regulation by emphasizing the dialectical connection between the broad historical processes of change and the local settings in which those changes are exerting an influence on health and illness. Seen in this light, ethnography and social history would seem to be the means by which medical ethicists can obtain culturally valid understanding of the sources and consequences of societal ethics. If we can talk of communities of fate with respect to shared infant mortality rates, job opportunities, and other life chances, then surely we should also be permitted to talk of communities of shared fate with respect to justice; that is how an anthropologically informed ethics should talk. Whether this will be achieved through interdisciplinary collaboration, through the retraining of professionals, or by drawing larger numbers of anthropologists, sociologists, and historians into medical ethics is still an open question.

What are the limits of cultural analysis, cross-cultural comparison, and the sensibility to variation and difference that are the core of the anthropologist's "cultural relativism"? Ethnography can overemphasize the extreme, the exotic case, and not give enough emphasis to the ordinary. The focus for cultural analysis can be so narrow that it encumbers rather than fosters comparisons. In the current era, the privileging of variation and difference can be so automatic and one-sided that there is a partial blindness to the other side of social life: what is shared across human conditions. Ethnographic privileging of interpretive methods may encourage unwarranted rejection of all quantitative approaches and findings. And cultural analysis, when carried to an extreme, can at times reproduce hermeneutic circles that are unhelpful and that discourage the movement from research to practice. Self-reflectivity can also be overdone, as can a reverse ethnocentricism that always privileges the other. But these are correctable faults that the best ethnographies manage to get around. A common and more fundamental critique centers on "cultural relativism."[6]

While epistemological and even ontological relativism—willingness to entertain the idea that there is no single form of knowledge or being in local worlds—will seem defensible to many, ethical relativism of the radical variety, the idea that there are no ethical standards cross-culturally, will not.[7] Critics complain: Are infanticide of female children in South Asia, ritual murder of elderly women accused of being illness-causing witches in East Africa, pharaonic circumcision and infibulation of five-year-old Sudanese girls that leave a pinhole for micturition and, later, menstruation, and rationing of care based on color status under apartheid acceptable because the dominant group says they are the way things should be? Clearly, this would be an unacceptable conclusion. Behind it lurks the terrible transmogrification of medicine under the Nazis, where biomedical ideology and technology, dominated by Nazi values, prepared the way to the death camps (Kleinman 1988b:104–107; Proctor 1988). It is this fear that E. D. Pellegrino (1993), one of the founders of medical ethics, arrogates to dismiss culturalist and postmodernist writings as assaults on the universality of truth, virtue, and the good: in his view the only sure grounds for medical ethics.

The anthropological argument advanced in these pages is for elicitation of and engagement with alternative ethical formulations, a constrained and engaged relativism; it is for affirmation of differences, not automatic authorization of any standard of practice as ethically acceptable because it is held by some people, somewhere (Shweder 1990; Wong 1984). The limit to ethical relativism is that the bioethicist (and the anthropologist) must compare an alternative ethical formulation with those ethical standards she or he holds for the evaluation of a particular problem in a particular context. The outcome of such an evaluation could be acceptance or rejection of the alternative or of the bioethicist's (or anthropologist's) own standard, or negotiation and compromise.

The idea of radical ethical relativism is unacceptable to all but a small group of diehards. It is, in my own view at least, a serious misinterpretation of what ethnography, cultural analysis, and cross-cultural comparison are about: namely, the commitment that before we apply an ethical category we hold to be universal, we had better first understand the context of practice and experience. The job should be to situate a problem in bioethics—clinical or societal—in a deep description of that particular ethos in order to understand what is at stake for the participants, what is contested, and thereby to offer a cultural formulation of conflicting ethical priorities. To do so implies the development of a cultural critique of bioethical discourse in its originating Western context and in its position within the globalization of markets, the media, and professional practice. Those descriptive and self-reflective activities having been done, there are at least three further steps in dealing with societal or clinical ethics. First, we need to systematically compare lay and professional bioethical standards for a particular problem in the contexts of a particular policy's or clinical procedure's social values; second, we need to identify ethical difference and to negotiate that part of the difference on which the various parties deem it ethical to compromise; and third, where a cross-cultural ethical conflict cannot be so resolved, the parties should specify the nature of the problem for further adjudication (Kleinman 1982).

That a cultural question in the ethics of suffering and healing cannot be resolved is not surprising and is not nearly as troubling as failure to engage it as an ethical issue. This ethnographic strategy does not commit the deep error of assuming that "all goods, all virtues, all ideals are compatible, and that what is desirable can alternatively be united into a harmonious whole without loss" (Williams 1981:xvi). Compromise and negotiation may not resolve ethical conflicts, and even where they do, some losses must occur. By definition ethical dilemmas leave a sense of remorse and regret. The quest is not for agreement on a transcendent (transpositionally objective) universal but for positioned pluralism. Indeed, identifying the deep sources of local ethical conflict may be more important for authorizing the process of cultural engagement in general than for handling a particular case.

Where possible, it is the obligation of the anthropologically informed bioethicist not only to respect the specific views of others and to affirm the validity of the process of formulating moral alternatives but also to develop deep knowledge about those positioned Weltanschauung in order to engage with alternative categories and practices as a potential way to resolve ethical conflict. This ethnographic approach emphasizes the process of engagement and negotiation with the engaged moral orientations of others; it attempts to minimize the application of bioethical categories that derive from the Western philosophical tradition to settings for which they lack coherence and validity. It attempts to prevent a commitment to that ethical tradition from becoming a kind of partisanship that "knows the answers to the questions it asks" (Sluga 1993:5). The ethnographic approach is not averse to leaving questions undecided.[8] The ethnographic vision recognizes the limits of our knowledge. Social experience always exceeds our grasp; description can never be complete. A large residue of human experience resists or exceeds understanding. This perspective also attempts to introduce sensitivity to the way ethical positions are contested locally as well as recognition that what may seem to an outside expert to be an ethical conflict may in fact represent a conflict over local resources or a form of resistance to state and professional control.

In other areas of cross-cultural research and practice, sensitivity to cultural difference and professional bias is established procedure. This approach also protects the responsibility of the professional consultant not to accept value decisions that contravene human rights and other pan-national moral conventions. But it makes that universalist responsibility the final stage in a lengthy process of cultural translation that gives priority, initially at least, to the social reality of alternative worlds of experience interpreted in their own terms.[9]

In this respect, an anthropological approach to medical ethics would have much in common with William Connolly's (1993b) version of an ethic of agonistic generosity. If ethical and political positions are always contingent so that there is no fundamental, intrinsic ethical and political ground, but each belongs to a historical epoch and cultural context, then what is required, Connolly avers, is that each position be presented strongly but that the presenters must also accord contesting views affirmation as alternatives that have to be taken seriously, that have to be brought into a process of critical moral and political engagement. Recognition of and respect for alternatives (not patronizing attitudes, but genuine expression of the worth of difference) are central to a process that moves from empathic affirmation through critical assessment toward encouragement of contestation and ultimately to constructive integration or resolution of another sort. (See Kekes 1993 on value incommensurability and the unavoidability of conflicts, as well as the place of conflict resolution, in a pluralist version of ethics.)

A number of these sensibilities are brought together in Joan Tronto's(1993) notion of an ethics and politics of care. Drawing upon various sources in feminist studies, Tronto describes care as a practice of reciprocation involving "caring-receiving." The process of care embraces attentiveness, responsibility, competence, responsiveness. It requires moral engagement as a political form of life, a way of acting that simultaneously engages the power of context and the context of power. Tronto seeks to establish caring as an alternative language for policy as much as for ordinary human interactions. John Caputo (1993), in Against Ethics, a curious combination of substantive thought and egregious exuberance, makes a complementary argument for understanding obligation in the face of social exigency as the grounds of moral experience, a "language game" that challenges the Western canon's discourse on ethics. For Caputo the social sources of obligation create a subject who suffers the powerful constraints of social history (p. 11) as much as she or he is active as an agent of choice (pp. 95–97). The process of events, especially disastrous ones (p. 29)—occurring, blowing up, resolving—creates a field of obligation and response, which inter alia, lends to powerlessness its power (p. 5) and to moral life its undecidability and its passion.

Such interpositional engagement is very much in the ethnographic mode. It also echoes Emmanuel Levinas's (1988:156–167) idea that morality is a process of interaction that results from a person's empathy for the suffering of "the Other." That empathic interaction creates the ethical as an "inter-human" experience of "suffering for the suffering of someone else." Or put differently, only in the engagement with the Other (and with what is at stake for that person, family, or community)—in a cross-personal interaction modeled on the lines of a cross-cultural one—does ethics emerge as a process of moral enactment that is sustainable in a multicultural world.

Of course there is no anthropological consensus for doing medical ethics. Complementary to, yet still different than, the anthropological way I have fashioned would be a Gramscian emphasis on the creation of "strategies of interference." By applying such strategies, practitioners would assist patients and families in disrupting or otherwise resisting the dominant institutional discourse with its tendency to commodify and to prescribe uniform, one-size-fits-all, practices. Although such a vision is too easily romanticized, when in fact its limits and potentially dangerous side effects are apparent, there is something to be recommended for bioethicists, only in carefully defined contexts of course, in considering obstructing the institutional efficiency of routinizing guidelines that they believe undermine care on behalf of the poetics of the experience of illness and the humanity of the clinical encounter. This is likely to be controversial; in fact, clinical consultants of many kinds, in my experience, silently apply something like this strategy on occasion in the hospital when they have identified the institution itself as the chief obstacle to good care. The tension that already exists in bioethics between the theoretical and the applied would likely be intensified by this way of proceeding, but that might be salubrious, both for the field and for its audiences (cf. Hoffmaster 1992; Pellegrino 1993).

The cardinal contribution of the anthropologist of medicine to bioethics, then, is to deeply humanize the process of formulating an ethical problem by allowing variation and pluralism and the constraints of social positions to emerge and receive their due, so that ethical standards are not imposed in an alien and authoritarian way but, rather, are actualized as the outcome of reciprocal participatory engagement across different worlds of experience. This would be a way of doing the work of ethics that is parallel to what the distinguished moral theorist Martha Nussbaum (1990:141) has pointed to in the work of Henry James as a narrative ethic that authorizes the moral sensibility of the ethicist. She writes.

Human deliberation is constantly an adventure of the personality, undertaken against terrific odds and among frightening mysteries, and … this is, in fact, the source of much of its beauty and richness, that texts written in a traditional philosophical style have the most insuperable difficulty conveying to us. If our moral lives are "stories" in which mystery and risk play a central and a valuable role, then it may well seem that the "intelligent report" of those lives requires the abilities and techniques of the teller of stories. (p. 142)

Ethnographic stories and literary stories are not the same, yet both genres draw upon a sensibility to context, the confounding connective tissue of intersubjectivity, and the ambiguous figures in the multiplicity of experience that would seem an essential tool also for bioethicists, if they are to avoid constructing an artifact of rational choice that inevitably will homogenize and therefore possibly dehumanize sufferers.

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